Provider Demographics
NPI:1629490586
Name:INTAKE, LLC
Entity Type:Organization
Organization Name:INTAKE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KOUROSH
Authorized Official - Middle Name:K
Authorized Official - Last Name:MORADMAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-422-6038
Mailing Address - Street 1:115 RIVER RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-1034
Mailing Address - Country:US
Mailing Address - Phone:201-366-4155
Mailing Address - Fax:
Practice Address - Street 1:115 RIVER RD
Practice Address - Street 2:SUITE 201
Practice Address - City:EDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:07020-1034
Practice Address - Country:US
Practice Address - Phone:201-366-4155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-13
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage